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Chapter 7
Hand Coverage Francisco Martinez Martinez, Martinez Martinez, Francisco M. Llanos Guerrero Guerrero Navarro, Navarro, Juan Garcia Navarro, M. Llanos Alberto Gimenez RosAlberto and Juan Garcia Navarro, Gimenez Ros and Alba Izquierdo Robledano Izquierdo Robledano Additional is available available at at the the end end of of the the chapter chapter Additional information information is http://dx.doi.org/10.5772/intechopen.74152
Abstract Hand and inger soft tissue defects have always represented a surgical challenge at any accident and emergency department. Techniques may vary from just direct closure of the wound to free tissue transfer. Knowledge of the main locoregional hand laps is paramount to solve most of the soft tissue defects at this level. Flaps vary depending on their blood supply and design. Their vascularity might be at random, they can be pedicled with anterograde or reversed low or they can rely on simple or complex free tissue transfer whose blood low depends on vascular anastomosis. This article reviews all the main soft tissue local or locoregional reconstructive techniques for hands and ingers. Keywords: hand coverage, hand reconstruction, ingertip reconstruction, soft tissue defect
1. Introduction Soft tissue coverage represents an essential part of the treatment of a traumatic hand. Conservative approach of soft tissue loss may lead to irreversible stifness and in some cases a higher chance of infection. The design of diferent laps for the hand has been the result of an improvement in the knowledge of hand neurovascular anatomy as well as their hemodynamic behaviour. This has allowed the development of an immense variety of regional laps to it a wide range of soft tissue problems.
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. distribution, and reproduction in any medium, provided the original work is properly cited.
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Before all this knowledge, laps were harvested at random, and a 2:1 width to length relation was a necessary condition in order to ensure the survival of a lap. This represented an important limitation to solve the diferent soft tissue challenges. The description of pedicled laps importantly increased the possibilities of coverage. The irst neurovascular pedicled island lap was described by Litler [1]. Reverse-low pedicled lap was irst described by Foucher [3] based on the distal anastomotic connections with the dorsal metacarpal arteries, which were found in anatomy studies. Besides, the later description of perforator laps also simpliied the reconstructive techniques, avoiding the sacriice of important vascular structures. Pollicisation of the index inger, already performed in congenital hand cases, was also applied in traumatic loss of the thumb. Eventually, the development of microsurgical advanced techniques such as toe to inger transfer for partial or complete amputation of a inger was an important asset in cosmesis and function. Currently, our efort has also been focused not merely on coverage but also on reducing donor site morbidity; techniques leading to incapacitating neuralgias or scars have to be avoided. In some patients, this type of pain may represent a more serious problem than stifness itself. There are diferent possibilities of coverage depending on the tissue exposed and its location. This chapter will only deal with locoregional basic laps.
2. Split- and full-thickness skin grafts This type of technique (Figure 1) can only be used when bones or tendons are not exposed. Due to inevitable contracture after the graft has taken, most patients will need some sort of
Figure 1. Skin grafts: (a) full-thickness skin grafts applied to the dorsum of the hands, (b) donor site of split-thickness skin grafts, (c) split-thickness skin graft meshed and (d) split-thickness skin graft.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
hand physiotherapy. This is even more the case, when partial-thickness skin grafts have been used. This type of graft is more prone to contract after having taken. Split-thickness skin grafts have to be harvested with the help of a dermatome and must be 0.25– 0.3 mm wide. Thicker grafts may lead to a non-healing donor site plus a less chance of graft taking. They are often meshed in order to increase their size and to allow exudate to escape. Full-thickness skin grafts are usually used in inger coverage. One of the reasons is that the amount of the skin to cover a defect in ingers is small enough to be easily obtained from the groin, the wrist or even the anterior skin of the arm or forearm. Also, this type of graft tends to contract less that the split one allows a beter functional and cosmetic result.
3. Local laps for the dorsum of the hand The dorsal skin of the hand is particularly elastic, and diferent local laps can be performed in order to cover small defects. The blood supply is mostly at random in these laps. They might be useful when small to moderate defects are approached and mostly if bone or tendons are exposed. The palmar skin of the hand can be considered the opposite in these terms. Local laps will not usually solve any coverage diiculty. Cuadrangular skin advancements and rotational laps are simple and allow stable coverage with optimal rates of survival. Limberg or Dufourmentel (Figure 2) laps are local cuadrangular transposition laps. These are mostly performed in elective surgery such as excisional removal of lesions [2].
Figure 2. Limberg’s and Dufourmentel’s laps.
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4. Coverage of the palm of the hand 4.1. Radial fasciocutaneous lap Described by Yang [4] in 1981 as a free lap for the hand, this is a fasciocutaneous island lap based on the radial artery. Currently, it is not considered the irst surgical option due to inevitable sacriice of the radial artery and possible donor site morbidity. Allen’s test is performed before surgical planning (Figure 3). When the objective is palm coverage, the design of the paddle starts in the middle third of the forearm between the brachioradialis (BR) and the lexor carpi radialis (FCR). The dissection can be performed suprafascially, but once the septum in between the two muscles is reached, the fascia along with the septum and the artery has to be included. The peritenons of the FCR and BR must not be injured. The cephalic vein is usually necessary when harvesting a free lap but not in the case of a reverse-low type, in which only concomitant veins are needed. The artery will be ligated at the proximal aspect of the lap. The arterial blood low to the radial artery occurs through the distal ulnar artery connections in the vascular palmar arches; thus, this will then be considered a reverse-low island lap. The same lap can also be raised as an adipofascial lap in order to reduce morbidity of the donor site, but then again the lap itself will have to be grafted. An osteocutaneous radial lap
Figure 3. Fasciocutaneous radial lap: (a) retrograde fasciocutaneous radial lap, (b) radial perforator lap and (c) clinical case of a retrograde fasciocutaneous radial lap for a defect of the palm of the hand.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
has also been described. In this case a small portion of the radius diaphysis is taken along with the artery. This type of reconstruction has been widely used as a free lap and not much as a pedicled lap. A perforator radial lap has also been described based on about ten existent perforating vessels (0.3–0.5 mm in diameter) located 2–4 cm proximal to the radial styloid process. To raise an adipofasciocutaneous lap, the territory will be marked over the proximal or middle third of the volar aspect of the forearm, with the pivot point about 2–4 cm proximal to the radial styloid. The proximal perforators can be ligated leaving the distal ones intact. The lap can be also potentially raised as an adipofascial lap [5]. 4.2. Glabrous skin lap Orbay et al. [6] described a lap based on a supericial cutaneous branch of the radial artery at the thenar eminence (Figure 4). The supericial palmar arch is mainly formed by the ulnar artery, less so the supericial branch of the radial artery emerges 1–2 cm proximal to the wrist fold before dividing into supericial and dorsal branches (the later one eventually enters Guyon’s canal). The supericial radial branch courses underneath the palmar fascia and irrigates the thenar eminence before proceeding under the adductor and opponens muscles. At the level of the insertion of the FCR, the cutaneous branch of the supericial radial artery perforates the palmar
Figure 4. Reverse-low lap based on the anastomosis of the supericial palmar branch of the radial artery with the vascular palmar arches. Notice the 180° arc of rotation of the lap.
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fascia; this level corresponds to a point 0.5–1 cm radial to the cutaneous thenar fold. A distal perforating vessel from the profundus or the supericial arch emerges at the conluency of Kaplan’s line with the second webspace axis. The lap can then be raised based on the proximal cutaneous perforator and down to the radial supericial artery. Thus raised, the lap can be used as a free lap. Based on the distal perforators, it can also be designed to be a retrograde lap and can be used to solve irst web contractures. In this case the supericial radial branch must be ligated proximal to the skin paddle.
5. Coverage of the dorsum of the hand 5.1. Posterior interosseous fasciocutaneous lap Described by Zancolli and Angrigiani [7] in 1988 for the dorsal coverage of the hand, this lap is based on the existence of an anastomosis between the posterior interosseous artery and the dorsal branch of the anterior interosseous artery at the dorsal aspect of the wrist. The posterior interosseous artery will be ligated, and the blood low will course retrogradely from the anterior interosseous artery to the posterior interosseous pedicle (Figure 5).
Figure 5. Interosseous posterior lap: (a) defect located on the dorsum of the hand and markings of the lap, (b) septum between the ifth and sixth extensor compartment where a cutaneous perforator can be visualized, (c) the lap harvested and (d) the inal outcome.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
The design of the posterior interosseous lap starts with the marking of the cutaneous island. A line is drawn between the lateral humeral epicondyle and the distal radioulnar joint. The island must be outlined in between the proximal and distal thirds of the forearm. The main posterior interosseous cutaneous branch emerges 9 centimetres distal to the lateral epicondyle in the same line; this can also be easily identiied with a Doppler ultrasound. The vascular anastomosis between the two interosseous arteries can be found 2 cm proximal to the radiocarpal joint at the proximal border of the pronator quadratus. The interosseous posterior artery is found at the septum between the extensor carpi ulnaris (ECU) and the extensor digiti minimi (EDM). This septum and the anastomosis are easily identiied distally, which is the reason why many surgeons prefer to irst identify the anastomosis and the posterior interosseous artery and eventually raise the lap. The posterior interosseous artery is closely related with the posterior interosseous nerve. This condition might represent a challenge in the hands of an inexperienced surgeon. Donor site may be close directly or with a split skin graft depending on the width of the cutaneous island.
Figure 6. Dorsoulnar fasciocutaneous lap: (a) anatomy of the distal dorsal branch of the ulnar artery and elevation of the lap based on the distal anastomosis of the ascending branch with the dorsal radial arch and the cutaneous ulnar branch needs to be ligated in order to perform a retrograde lap (black line) and (b) clinical case of dorsoulnar fasciocutaneous lap to cover a defect of the palm.
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5.2. Dorsoulnar fasciocutaneous lap This is a lap that is based on the distal branch of the ulnar artery which emerges 2–5 cm proximal to the pisiform bone. This branch courses between the lexor carpi ulnaris (FCU) and the ECU and then reaches the cutaneous skin crossing between the ulnar nerve and the FCU distally. It then divides into descending and ascending branches. The descending branch anastomoses with skin perforators of the dorsal arch (Figure 6). This distal branch can be identified with Doppler ultrasound. The flap can then be raised as a propeller flap (rotating the fasciocutaneous island around this branch) or as a reversed flap based on the anastomosis with the descending branch. This second option allows further advancement. This flap reaches the fourth and the fifth metacarpophalangeal joints. Bertelli and Pagliei [8] have made an anatomic description of an osteocutaneous lap based on the ulnar periosteal branches of the ascending branch.
6. Finger coverage 6.1. Cross-inger lap The cross-inger lap is a two-stage lap reconstruction that was irst described by Cronin in 1951 [9] (Figure 7). This lap can be easily raised due to the fact that it does not require the dissection of vascular pedicles. It is a transposition lap based on the subcutaneous dorsal branches of a proper palm digital artery (PDA). The fact that this is a two-stage surgical technique is the main disadvantage. This lap is frequently designed over the dorsal skin of a medial phalanx in order to cover a distal phalanx or a medial phalanx of a contiguous inger. The limits of lap dissection are always represented by the inger folds. The vascular base of the lap is located at the mediolateral line of the donor inger that is directly opposite to the defect on the adjacent inger. In the case of volar skin loss, the lap has to be raised based on the dorsal skin of the medial phalanx of the donor inger. In case of dorsal skin loss, the coverage will be performed based on the volar aspect instead. Dissection must include the skin and subcutaneous tissue, and the tendon sheath should not be exposed. The donor site has to be covered with a full-thickness skin graft. The donor and recipient inger should be buddy splinted for 2 weeks. The second surgical step is then performed and the syndactyly is released. Hand physiotherapy will be necessary after the surgical procedure has been completed. This type of coverage is particularly interesting for the triphalangeal ingers. The middle inger acts as a proper donor for the index and ring ingers. Litle inger injuries require the skin
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
Figure 7. Cross-inger lap: (a and b) defect and markings of the lap and (c, d and e) clinical case; always preserve the peritenon to be able to apply a skin graft on the donor digit.
from the ring inger. This lap is not a good option for the coverage of the tip of the middle inger, because the ring or the index medial phalanges are more proximally located and the middle inger needs to be forced into lexion in order to it next to them. 6.2. Thenar lap This lap has also been described for the reconstruction of the tip of the long ingers. This is not only a simple technique but also needs a two-step procedure (Figure 8). The skin is taken from the radial aspect of the thenar eminence, proximal to the metacarpophalangeal fold. Despite of its name, scars at the thenar eminence should be avoided above all the weight-bearing central axis of the thenar eminence. The base of the lap can be cranially or caudally located. The donor site needs to be grafted. 6.3. V to Y Atasoy lap This triangular advancement lap was described by Tranquili [10] and popularised by Atasoy [11]. This lap is indicated in the case of transverse or dorsally oblique amputation of the tip of the ingers (Figure 9a).
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Figure 8. Thenar lap: (a and b) schema and (c and d) clinical case.
This lap is one of the most frequently performed in the emergency department but can be advanced only up to 7 to 8 mms. If higher expectations are sought, this lap would not be suitable. Inexperienced surgeons may tend to skeletonize the base of the lap or suture it under tension; any of these situations lead to inevitable lap necrosis. The design of the lap is marked on the volar aspect of the afected distal phalanx down to the distal fold. The subcutaneous tissue can be fully elevated from the tendon sheath. The skin will only be incised supericially (i.e. until the subcutaneous tissue appears). Once dissected, the distal aspect of the lap is ixed with the help of a small needle rather than direct sutures, because direct suturing may damage the nail bed. The skin must be closed in a V to Y fashion in order to advance the lap. 6.4. Bilateral V to Y Kutler’s lap This bilateral lap was described by Kutler [12] in 1930; it is based on the same principles as the V to Y lap (Figure 9b). The Vs are marked at both sides of the defect, taking into account that they will be irrigated by the small branches of the proper palmar digital arteries.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
Figure 9. (a) Atasoy’s lap and (b) Kutler’s lap.
As a main drawback, this lap leaves an unpleasant longitudinal linear scar at the tip of the inger. 6.5. Homodigital pedicled island laps 6.5.1. Oblique triangular neurovascular lap This lap was described by Venkataswami and Subramanian [13] in 1980; it is mostly suitable for oblique ingertip amputations. The lap is based on the vascular pedicle opposite
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the amputated side. The base of the triangular lap lies adjacent to de amputated side. A vertical incision is performed in the midlateral line of the inger down to the periosteum, and the pedicle of the inger is visualised and fully raised avoiding skeletonization. A partial thickness oblique incision is then performed; only the ibrous septa are divided to allow lap advancement (Figure 10). The apex of the triangle is usually marked at the PIP joint. Small islands will tend to contract in time. Therefore, the island should never be small in size. Unlike most unipedicled digital laps, it contains the digital nerve of the lap and branches of the contralateral digital nerve. It cannot be considered as a true island lap but the irst step just before that. In case the advancement provided is insuicient, decision has to be made as to whether a true island lap is needed. 6.5.2. Homodigital neurovascular anterograde unipedicled island lap This was described by Litler [1] although as a heterodigital lap. The design of the lap is subject to the location of the lesion. Despite of that, Brunelli described some considerations as to which donor site is more advisable in order to leave intact the dominant hemipulp. Advisable donor sites are the ulnar aspect of the index and middle ingers as well as the radial aspect of the ring and litle ingers (Figures 11 and 12). A U-shaped lap is marked, proximal to the defect, apex based at the PIP joint. The vertical incision reaches the periosteum, and once again, the pedicle must be visualised and not skeletonized to preserve a suitable venous drainage. The oblique incision also reaches the tendon sheath, and the lap would inally only be atached by its pedicle. The advancement can be
Figure 10. Neurovascular island lap and Venkataswami’s lap.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
Figure 11. Homodigital anterograde neurovascular lap.
improved by releasing the pedicle down to the base of the inger. Brunner or hemi-Brunner incisions are then performed to avoid scar contractures in the future. A full-thickness skin graft is hardly ever necessary to cover the donor site. A splint is advisable in the irst week to prevent tension of the pedicle; the MCP joints should be kept lexed and the DIP and PIP joints extended. Hand physiotherapy is paramount to fully recover function. This lap is not suitable for patients with peripheral vascular disease or in digits nourished by a single vessel. 6.5.3. Homodigital quadrangular lap Described in 1966 by Hueston [14], this lap is meant to be advanced and rotated to reach the defect. It is based on one of the neurovascular pedicles and is eligible for transverse defects. Further dissection of the pedicle down to the base of the inger is not performed (Figures 13 and 14). The island paddle is outlined at the midaxial lateral line of the less afected side, or in case of a complete transverse amputation, the lateral line transected will correspond to the nondominant side. Therefore, this lap will be based on the dominant neurovascular pedicle. The lap is elevated and the tendon sheath will be left intact. The lap will then be advanced and rotated to cover the area of defect. The proximal end will be closed in a V to Y fashion or with a skin graft if needed.
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Figure 12. Clinical case of a homodigital anterograde neurovascular lap: (a) distal amputation, (b) lap dissection, (c) result at the end of the surgery and (d) the inal outcome.
6.5.4. Homodigital neurovascular retrograde unipedicled lap Described by Lai [15] in 1989, this lap is outlined on the lateral nondominant border of the base of the afected digit. The availability of the skin paddle is larger than the one for the anterograde lap (Figure 15). Elevation is carried out from proximal to distal until enough length of the pedicle is obtained. The vascularity of this lap is dependent on transverse commissural arteries found at the PIP and DIP joints. Therefore, dissection should not proceed more than 1 cm proximal to the DIP joint. During dissection the proper digital nerve (PDN) is gently separated from the vascular pedicle, and the digital vessel is ligated proximally. The artery must be raised along with a cuf of fat and again never skeletonised the pedicle. A full-thickness skin graft is used to close the secondary defect at the donor site. The lap described is a non-sensate lap, and the PDN is left buried under a skin graft, which in some cases may be the cause of scar donor site dysaesthesias. A retrograde sensate lap has also been described, including the PDN along with the artery. Once the lap reaches the defect, the nerve needs to be sutured to the amputated contralateral nerve in order to achieve sensation.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
Figure 13. Hueston’s lap: (a) schema of the lap for a thumb defect and (b) schema of the lap for a triphalangeal inger.
Figure 14. Clinical case of homodigital cuadrangular lap after necrosis of the tip of the middle inger.
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Figure 15. Homodigital retrograde neurovascular lap. The vascular conections of the proper palmar digital arteries are represented on the left image.
The main drawback is the fact that the stump of the donor nerve might turn into a neuroma and neuralgic pain may be quite invalidating. 6.5.5. Homodigital bipedicled island lap for the thumb Moberg [16] irst described this lap in 1964, which consisted of undermining of the volar skin from the dorsal aspect along the midaxial lines of the thumb, starting proximal to the defect. The quadrangular advancement of the volar skin includes the two proper digital arteries and nerves. The arterial supply of the thumb difers from other ingers. Whereas the volar side of the thumb is supplied by two palmar collateral arteries which are branches of the princeps pollicis artery, the dorsal skin is predominantly supplied by ulnar and radial dorsolateral arteries and branches of the dorsal branch of the radial artery. Due to this particular vascularity, this lap can be raised to cover distal defects of the thumb but can potentially cause dorsal skin necrosis in triphalangeal ingers. The IP joint of the thumb should be kept lexed at 15–20° for a week, and later on hand physiotherapy is advised (Figure 16). O’Brien [17] modiied this lap in order to avoid lexion contractures. He added a skin incision distal to the MCP fold. Both pedicles are visualised and left intact with surrounding the subcutaneous tissue. This technique allows further advancement of the lap. A graft is then placed to cover this secondary defect. 6.5.6. Homodigital unipedicle retrograde island lap for the thumb This lap was described by Brunelli [18]. The skin paddle is designed over the dorsoulnar aspect of the irst metacarpal distal to the emergence of the dorsal branch of the radial artery in the irst webspace. Dorsoulnar and dorsoradial arteries for the thumb branch out directly from the radial artery or from the irst dorsal interosseous artery. This axial lap carries the
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
Figure 16. Möberg’s lap.
dorsoulnar branch of the thumb which anastomoses with the thumb proper ulnar artery at the neck of the proximal phalanx. The dorsoulnar artery needs to be ligated proximal to the island paddle, and dissection is performed from distal to proximal (Figures 17 and 18). The lap can potentially include radial sensory branches found near the dorsoulnar branch which can then be sutured to the proper digital nerve to atempt a sensate type of lap. Otherwise, this lap will not provide sensation to the tip of the thumb. A similar lap has been described based on the dorsoradial artery of the thumb [19]. However, the dorsoulnar branch is considered more dominant and constant.
Figure 17. Brunelli’s lap.
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Figure 18. Clinical case of homodigital dorsoulnar retrograde lap for the tip of the thumb.
Cavadas [20] described a modiication that included a small portion of the irst metacarpal diaphysis. This was presented as an option for complex injuries with a severe bone defect at the distal phalanx. 6.6. Heterodigital laps 6.6.1. Litler neurovascular island lap Currently, this type of reconstruction has lost popularity. The previously described anterograde homodigital laps and microsurgical procedures such as toe to pulp transfer have limited its use. It is still interesting in case of a spare skin paddle and corresponding neurovascular pedicle of an otherwise nonsalvageable digit. This can then be used to reconstruct other injured digits but mainly for thumb reconstruction (Figure 19). The selected donor site is the ulnar aspect of the middle and ring ingers. The skin paddle is marked; it extends from the volar midline until the dorsal midline. The pedicle dissection must be continued until the supericial palmar arch has been reached. A cuf of perivascular tissue needs to be preserved; after releasing the natatory ibres of the palmar fascia, the proper digital artery of the adjacent inger is ligated at the bifurcation of the common palmar digital artery, and the dissection of the pedicle is then accomplished up to the supericial arch. Brunner and hemi-Brunner types of incisions in both zone II and zone III have to be done in order to reach the proper pedicle length. The island lap has to be transferred without tension, kinking or compression through a subcutaneous tunnel to the thumb. The sensory integration of the lap is variable, and the older the patient is, the less recognition will take place. However, this is not essential to reach adequate function. The donor site needs skin grafting.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
Figure 19. Litler’s lap and heterodigital hemipulp neurovascular lap.
6.7. Metacarpal artery island laps 6.7.1. First dorsal metacarpal artery lap The so-called cerf-volant was described by Foucher and Braun [21] and has been considered the main workhorse in thumb reconstruction (Figures 20 and 21). Based on the irst dorsal metacarpal artery (FDMA), which is a branch of the dorsal radial artery of the hand, it courses parallel to the irst metacarpal bone and supericial to the irst dorsal interosseous muscle fascia although some ibres may cover the vessel at its course. The FDMA has vascular connections with the PDA at the level of the metacarpal neck. The island paddle is outlined at the dorsal skin of the proximal phalanx. It extends from the PIP joint to the MCP joint. Laterally, it can extend from the radial midline to the ulnar midline of the inger. Dissection has to be carried out subfascially in order not to damage the pedicle.
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Figure 20. Cerf-volant Foucher’s lap, based on the irst dorsal interosseous artery.
Figure 21. Clinical case of a defect of the tip of the thumb treated with a Foucher’s lap.
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A lazy S incision is performed from the MCP joint to the anatomic snubox. The pedicle is then released until its emergency at the dorsal radial artery. Subcutaneous veins and sensory branches of the radial nerve are identiied and can be included in the lap. A tunnel is dissected from the irst interosseous webspace to the defect at the tip of the thumb, and the lap and its pedicle are transferred and sutured. The pedicle must not be compressed under the tunnel, and the lap should be sutured tension-free. 6.7.2. Reverse-low dorsal metacarpal laps The dorsal metacarpal arteries (DMA) are branches of the dorsal arch supplied by the radial artery. They course underneath the extensor tendons, included in the epimysial lining of the dorsal interosseous muscles (Figures 22 and 23). Due to the vascular connections with the deep palmar arch through recurrent cutaneous branches, this lap can be raised retrogradely. These connections are found distal to the juncturae tendinum. Early and Milner [22] developed a reverse-low island lap, based on the dorsal metacarpal arteries. This lap includes the whole course of the metacarpal artery; at the proximal end, the artery is ligated. The dissection must leave the peritenon of the extensor tendon intact
Figure 22. Dorsal metacarpal laps of reverse low: (a) position of the skin paddles (ellipses) and pivotal points (red dots); (b) the pedicle includes the fascia of the dorsal interosseous muscle.
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Figure 23. Clinical case of skin defect on the proximal interphalangeal joint of the middle inger; the second dorsal metacarpal artery lap is performed.
Figure 24. Quaba Davison’s laps: (a) location of the skin paddles (ellipses) and pivotal points (red dots); (b) the lap does not include the fascia of the dorsal interosseous muscle, and the pivotal point is immediately distal to the juncturae tendinum.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
Figure 25. Clinical case of a volar defect at the medial phalanx: a Quaba Davison’s lap was used since many of the adjacent digits had been amputated.
Figure 26. Dorsal commissural laps: (a) location of the skin paddles (ellipses); (b) the lap reaches the distal interphalangeal joints and the distal phalanx.
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Figure 27. Clinical case of soft tissue defect on the medial phalanx where a dorsal commissural lap was obtained.
and include the interosseous fascia. The juncturae must be released, and dissection has to end at the level of the metacarpal neck. Dorsal sensory branches and possible veins must be included in the lap. The island paddle extends from the MCP joint to the wrist crease. The arc of rotation of this lap (180°) allows the coverage of the proximal phalanx and PIP joint up to the middle phalanx. Quaba and Davidson [23] described the same lap without incorporating the DMA (Figures 23 and 24). Dissection of the lap proceeds suprafascially, and it is based only on the recurrent cutaneous branch. The lap can also extend from the MCP joint to the wrist crease. The lap is then easier to elevate and provides a thinner coverage (Figures 25 and 26). Eventually, anatomic studies conirmed the existence of vascular connections at diferent levels of the proximal phalanx and medial phalanx between the PDA and cutaneous braches of the DMA. Karacalar and Özcan [24] described a modiied version of this lap based on these anatomic indings. This is a reverse-low lap with the skin paddle outlined on the second and third webspaces (Figure 27). The arc of rotation reaches the distal phalanx, and the pivot point is found at the neck of the proximal phalanx (Figures 25 and 26).
7. Summary Local hand laps ofer excellent coverage of soft tissue loss when a skin graft is not eligible and when the defect is small or moderate.
Hand Coverage http://dx.doi.org/10.5772/intechopen.74152
The knowledge of the neurovascular anatomy is paramount in order to understand and perform these laps. Most local laps provide adequate sensation and cosmesis using locoregional skin. However, local laps obviously have limited indications, and larger or complex cases need a microsurgical approach instead of or even further amputation if considered nonsalvageable. Surgeons should recognize which indication is correct in every case.
Author details Francisco Martinez Martinez1*, M. Llanos Guerrero Navarro2, Juan Garcia Navarro1, Alberto Gimenez Ros1 and Alba Izquierdo Robledano1 *Address all correspondence to:
[email protected] 1 Hospital Universitario Virgen de la Arrixaca, Murcia, Spain 2 Hospital General Universitario Santa Lucia, Cartagena, Murcia, Spain
References [1] Litler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. The Journal of Bone and Joint Surgery. American Volume. 1956;38:917 [2] Lister GD, Gibson T. Closure of rhomboid skin defects: The laps of Limberg and Dufourmentel. British Journal of Plastic Surgery. 1972;25(3):300-314 [3] Foucher G, Braun JB. A new island lap transfer from the dorsum of the index to the thumb. Plastic and Reconstructive Surgery. 1979;63(3):344-349 [4] Yang G, Chen B, Gao Y. The forearm free skin lap transplantation. National Medical Journal of China. 1981;61:139 [5] Medalie DA. Perforator-based forearm and hand adipofascial laps for the coverage of diicult dorsal hand wounds. Annals of Plastic Surgery. 2002;48(5):477-483 [6] Orbay JL, Rosen JG, Khouri RK, et al. The glabrous palmar lap: The new free or reversed pedicled palmar fasciocutaneous lap for volar hand reconstruction. Techniques in Hand & Upper Extremity Surgery. 2009;13(3):145-150 [7] Zancolli EA, Angrigiani C. Posterior interosseous island forearm lap. Journal of Hand Surgery British. 1988;13(2):130-135 [8] Bertelli JA, Pagliei A. The neurocutaneous lap based on the dorsal branches of the ulnar artery and nerve. A new lap for extensive reconstruction of the hand. Plastic and Reconstructive Surgery. 1998;101(6):1537-1543
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[9] Cronin TD. The cross inger lap: A new method of repair. The American Surgeon. 1951; 17(5):419-425 [10] Tranquilli-Leali E. Reconstruzione del apice falangi vaguali mediante autoplástica volare pedunculata per scorimento. Infort Traum Lavoro. 1935;1:186-193 [11] Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the amputated inger tip with a triangular volar lap. Journal of Bone and Joint Surgery. 1970;52:921-926 [12] Kutler W. A new method for ingertip amputation. Journal of the American Medical Association. 1947;133(1):29-30 [13] Venkataswami DR, Subramanian N. Oblique triangular lap: A new method of repair for oblique amputations of the ingertip and thumb. Plastic and Reconstructive Surgery. 1980;66(2):296-300 [14] Hueston JT. Local lap repair of ingertip injuries. Plastic and Reconstructive Surgery. 1966;37(4):349-350 [15] Lai CS, Ling SD, Yang CC. The reverse digital artery lap for ingertip reconstruction. Annals of Plastic Surgery. 1989;22(6):495-500 [16] Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. The Journal of Bone and Joint Surgery. American Volume. 1964;46:817-825 [17] O'Brien B. Neurovascular island pedicle laps for terminal amputations and digital scars. British Journal of Plastic Surgery. 1968;21(3):258-261 [18] Brunelli F, Vigasio A, Valenti P, Brunelli GR. Arterial anatomy and clinical application of the dorsoulnar lap of the thumb. Journal of Hand Surgery. 1999;24(4):803-811 [19] Bakhach J, Sentucq-Rigal J, Mouton P, Boileau R, Panconi B, Guimberteau JC. The dorsoradial lap: A new lap for hand reconstruction. Anatomical study and clinical applications. Annales de Chirurgie Plastique et Esthétique. 2006;51(1):53-60 [20] Cavadas P. Reverse osteocutaneous dorsoulnar thumb lap. Plastic and Reconstructive Surgery. 2003;111(1):326-329 [21] Foucher G, Braun J. A new island lap transfer from the dorsum of the index to the thumb. Plastic and Reconstructive Surgery. 1979;62(3):344-349 [22] Early MJ, Milner RH. Dorsal metacarpal laps. British Journal of Plastic Surgery. 1987; 10:333-341 [23] Quaba AA, Davidson PM. The distally-based dorsal hand lap. British Journal of Plastic Surgery. 1990;43(1):28-39 [24] Karacalar A, Özcan M. A new approach to the reverse dorsal metacarpal artery lap. Journal of Hand Surgery American. 1997;22(2):307-310
